Sedgwick
Overview
Be among the first 25 applicants. By joining Sedgwick, you\'ll be part of something truly meaningful. It\’s what our 33,000 colleagues do every day for people around the world who are facing the unexpected. We invite you to grow your career with us, experience our caring culture, and enjoy work-life balance. Here, there\’s no limit to what you can achieve.
As a Disability Representative Sr, you will provide disability case management and complex claim determinations based on medical documentation and the applicable disability plan interpretation. This includes determining benefits due, making timely payments/approvals and adjustments, medically managing disability claims (including comorbidities, concurrent plans, and complex ADA accommodations), coordinating investigative efforts, reviewing contested claims, negotiating return to work with or without job accommodations, and arranging referrals to outside vendors as needed.
Primary purpose PRIMARY PURPOSE : Provides disability case management and complex claim determinations based on medical documentation and the applicable disability plan interpretation including determining benefits due and making timely payments/approvals and adjustments, medically managing disability claims including comorbidities, concurrent plans, and complex ADA accommodations; coordinates investigative efforts, thoroughly reviews contested claims, negotiates return to work with or without job accommodations, and evaluates and arranges appropriate referral of claims to outside vendors.
Essential Functions and Responsibilities
Makes independent claim determinations, based on the information received, to approve complex disability claims or makes a recommendation to team lead to deny claims based on the disability plan.
Reviews and analyzes complex medical information (i.e. attending physician statements, office notes, operative reports, etc.) to determine if the claimant is disabled as defined by the disability plan.
Oversees additional facets of complex claims including but not limited to comorbidities, concurrent plans, complex ADA accommodations, and claims outside of typical guidelines.
Utilizes the appropriate clinical resources in case assessment (i.e. duration guidelines, in-house clinicians), as needed.
Determines benefits due pursuant to a disability plan, makes timely claims payments/approvals and adjustments for workers compensation, Social Security Disability Income (SSDI), and other disability offsets.
Informs claimants of documentation required to process claims, required time frames, payment information and claims status by phone, written correspondence and/or claims system.
Communicates with the claimants’ providers to set expectations regarding return to work.
Medically manages complex disability claims ensuring compliance with duration control guidelines and plan provisions.
Communicates clearly and timely with claimant and client on all aspects of claims process by phone, written correspondence and/or claims system.
Coordinates investigative efforts ensuring appropriateness; provides thorough review of contested claims.
Evaluates and arranges appropriate referral of claims to outside vendors or physician advisor reviews, surveillance, independent medical evaluation, functional capability evaluation, and/or related disability activities.
Negotiates return to work with or without job accommodations via the claimant’s physician and employer.
Refers cases to team lead and clinical case management for additional review when appropriate.
Maintains professional client relationships and provides excellent customer service.
Meets the organization’s quality program(s) minimum requirements.
Additional Functions and Responsibilities
Performs other duties as assigned.
Qualifications Education & Licensing High School diploma or GED required. Bachelor\'s degree from an accredited university or college preferred. State certification or licensing in statutory leaves is preferred or may be required based on state regulations.
Experience Three (3) years of benefits or disability case/claims management experience or equivalent combination of education and experience preferred.
Skills & Knowledge
Knowledge of ERISA regulations, required offsets and deductions, disability duration and medical management practices and Social Security application procedures
Knowledge of state and federal FMLA regulations
Working knowledge of medical terminology and duration management
Excellent oral and written communication, including presentation skills
Proficient computer skills including working knowledge of Microsoft Office
Analytical, interpretive, and critical thinking skills
Ability to manage ambiguity
Strong organizational and multitasking skills
Ability to work in a team environment
Ability to meet or exceed performance competencies as required by program
Effective decision-making and negotiation skills
Ability to exercise judgement autonomously within established procedures
Work Environment When applicable and appropriate, consideration will be given to reasonable accommodations.
Compensation and Benefits As required by law, Sedgwick provides a reasonable range of compensation for roles that may be hired in jurisdictions requiring pay transparency in job postings. The actual compensation is influenced by skill set, level of experience, and location. In the noted jurisdiction, the starting pay range is $23.32 - $25.00. A comprehensive benefits package is offered including medical, dental, vision, 401k and matching, PTO, disability and life insurance, employee assistance, flexible spending or health savings account, and other voluntary benefits.
Equal Opportunity and Employment Information Sedgwick is an Equal Opportunity Employer and a Drug-Free Workplace. Qualified applicants with arrest or conviction records will be considered for employment in accordance with applicable fair chance laws and ordinances.
Note If you\'re excited about this role but your experience doesn\'t align perfectly with every qualification in the job description, consider applying anyway. Sedgwick is building a diverse, equitable, and inclusive workplace and recognizes that each person possesses a unique combination of skills, knowledge, and experience.
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As a Disability Representative Sr, you will provide disability case management and complex claim determinations based on medical documentation and the applicable disability plan interpretation. This includes determining benefits due, making timely payments/approvals and adjustments, medically managing disability claims (including comorbidities, concurrent plans, and complex ADA accommodations), coordinating investigative efforts, reviewing contested claims, negotiating return to work with or without job accommodations, and arranging referrals to outside vendors as needed.
Primary purpose PRIMARY PURPOSE : Provides disability case management and complex claim determinations based on medical documentation and the applicable disability plan interpretation including determining benefits due and making timely payments/approvals and adjustments, medically managing disability claims including comorbidities, concurrent plans, and complex ADA accommodations; coordinates investigative efforts, thoroughly reviews contested claims, negotiates return to work with or without job accommodations, and evaluates and arranges appropriate referral of claims to outside vendors.
Essential Functions and Responsibilities
Makes independent claim determinations, based on the information received, to approve complex disability claims or makes a recommendation to team lead to deny claims based on the disability plan.
Reviews and analyzes complex medical information (i.e. attending physician statements, office notes, operative reports, etc.) to determine if the claimant is disabled as defined by the disability plan.
Oversees additional facets of complex claims including but not limited to comorbidities, concurrent plans, complex ADA accommodations, and claims outside of typical guidelines.
Utilizes the appropriate clinical resources in case assessment (i.e. duration guidelines, in-house clinicians), as needed.
Determines benefits due pursuant to a disability plan, makes timely claims payments/approvals and adjustments for workers compensation, Social Security Disability Income (SSDI), and other disability offsets.
Informs claimants of documentation required to process claims, required time frames, payment information and claims status by phone, written correspondence and/or claims system.
Communicates with the claimants’ providers to set expectations regarding return to work.
Medically manages complex disability claims ensuring compliance with duration control guidelines and plan provisions.
Communicates clearly and timely with claimant and client on all aspects of claims process by phone, written correspondence and/or claims system.
Coordinates investigative efforts ensuring appropriateness; provides thorough review of contested claims.
Evaluates and arranges appropriate referral of claims to outside vendors or physician advisor reviews, surveillance, independent medical evaluation, functional capability evaluation, and/or related disability activities.
Negotiates return to work with or without job accommodations via the claimant’s physician and employer.
Refers cases to team lead and clinical case management for additional review when appropriate.
Maintains professional client relationships and provides excellent customer service.
Meets the organization’s quality program(s) minimum requirements.
Additional Functions and Responsibilities
Performs other duties as assigned.
Qualifications Education & Licensing High School diploma or GED required. Bachelor\'s degree from an accredited university or college preferred. State certification or licensing in statutory leaves is preferred or may be required based on state regulations.
Experience Three (3) years of benefits or disability case/claims management experience or equivalent combination of education and experience preferred.
Skills & Knowledge
Knowledge of ERISA regulations, required offsets and deductions, disability duration and medical management practices and Social Security application procedures
Knowledge of state and federal FMLA regulations
Working knowledge of medical terminology and duration management
Excellent oral and written communication, including presentation skills
Proficient computer skills including working knowledge of Microsoft Office
Analytical, interpretive, and critical thinking skills
Ability to manage ambiguity
Strong organizational and multitasking skills
Ability to work in a team environment
Ability to meet or exceed performance competencies as required by program
Effective decision-making and negotiation skills
Ability to exercise judgement autonomously within established procedures
Work Environment When applicable and appropriate, consideration will be given to reasonable accommodations.
Compensation and Benefits As required by law, Sedgwick provides a reasonable range of compensation for roles that may be hired in jurisdictions requiring pay transparency in job postings. The actual compensation is influenced by skill set, level of experience, and location. In the noted jurisdiction, the starting pay range is $23.32 - $25.00. A comprehensive benefits package is offered including medical, dental, vision, 401k and matching, PTO, disability and life insurance, employee assistance, flexible spending or health savings account, and other voluntary benefits.
Equal Opportunity and Employment Information Sedgwick is an Equal Opportunity Employer and a Drug-Free Workplace. Qualified applicants with arrest or conviction records will be considered for employment in accordance with applicable fair chance laws and ordinances.
Note If you\'re excited about this role but your experience doesn\'t align perfectly with every qualification in the job description, consider applying anyway. Sedgwick is building a diverse, equitable, and inclusive workplace and recognizes that each person possesses a unique combination of skills, knowledge, and experience.
#J-18808-Ljbffr